Indications for Lumbar Total Disc Replacement: Selecting the Right Patient with the Right Indication for the Right Total Disc

Abstract

Summary of Background DataAs with any surgery, care should be taken to determine patient selection criteria for lumbar TDR based on safety and optimizing outcome. These goals may initially be addressed by analyzing biomechanical implant function and early clinical experience, ongoing evaluation is needed to refine indications.ObjectiveThe purpose of this work was to synthesize information published on general indications for lumbar TDR. A secondary objective was to determine if indications vary for different TDR designs.MethodsA comprehensive literature search was conducted to identify lumbar TDR articles. Articles were reviewed and patient selection criteria and indications were synthesized.ResultsWith respect to safety, there was good agreement in the literature to exclude patients with osteopenia/osteoporosis or fracture. Risk of injury to vascular structures due to the anterior approach was often addressed by excluding patients with previous abdominal surgery in the area of disc pathology or increased age. The literature was very consistent on the primary indication for TDR being painful disc degeneration unresponsive to at least 6 months of nonoperative care. Literature investigating the impact of previous spine surgery was mixed; however, prior surgery was not necessarily a contra-indication, provided the patient otherwise met selection criteria. The literature was mixed on setting a minimum preoperative disc height as a selection criterion. There were no publications investigating whether some patients are better/worse candidates for specific TDR designs. Based on the literature a proposal for patient selection criteria is offered.ConclusionsSeveral TDR indications and contra-indications are widely accepted. No literature addresses particular TDR design being preferable for some patients. As with any spine surgery, ongoing evaluation of TDR outcomes will likely lead to more detailed general and device design specific indications.

Chondrocyte death after mechanically overloading degenerated human intervertebral disk explants is associated with a structurally impaired pericellular matrix

“…However, this may lead to eventual adjacent segment degeneration (Ghiselli, Wang, Bhatia, Hsu, & Dawson, ). As modern disk arthroplasties cannot fully imitate the mechanical function of the native joint and can only be performed in a small subset of affected patients (Büttner‐Janz, Guyer, & Ohnmeiss, ), the available treatment options collectively highlight that the field would benefit from a better understanding of the underlying pathophysiology and causally acting interventions (Hanley et al, ). Indeed, first clinical regenerative approaches are emerging (Sakai & Andersson, ; Vadalà, Russo, Ambrosio, Loppini, & Denaro, ), but their long‐term clinical results (Tschugg, Michnacs, Strowitzki, Meisel, & Thomé, ) have not yet been evaluated.…”

Lumbar disc replacement surgery—successes and obstacles to widespread adoption

“…Taking the aforementioned points into account, lumbar TDR might be considered a viable treatment option in patients suffering from painful DDD unresponsive to more than 6 months of nonoperative care with diagnostic studies confirming the disc as the likely pain generator, and without significant facet joint degeneration, deformities, instabilities or osteopenia/osteoporosis [26].…”

Finite element analysis of a ball‐and‐socket artificial disc design to suppress excessive loading on facet joints: A comparative study with ProDisc

“…In addition, there are less adjacent‐level effects such as excessive range of motion (ROM), which can cause accelerated degeneration at adjacent level, than with that of conventional fusion methods . The major indication for TDR in the lumbar spine is symptomatic DDD, and various factors such as bone quality and source of pain are examined before the surgery …”

“…2,3 The major indication for TDR in the lumbar spine is symptomatic DDD, and various factors such as bone quality and source of pain are examined before the surgery. 4 The condition of facet joints is also an important factor in determining TDR in terms of contraindication: patients who have degenerative facet joints should be excluded from TDR, as the preserved spinal motion can cause adverse effects on the facet joints. Although TDR is limited to patients with DDD without facet joint problems, long-term follow-up clinical studies have reported progressive facet arthrosis as a major complication after TDR.…”